Early-life adversity and problem drinking in adulthood: Improving on the measurement of adverse childhood experiences.

Objectives. To examine how socioeconomic status (SES) shaped intraracial health disparities among Black women before, during, and after the COVID-19 pandemic. Methods. Using Behavioral Risk Factor Surveillance System data (2018-2023; n = 89 634 Black women), we analyzed temporal trends in self-rated health, days of poor physical and mental health, and SES (education, income, employment). Results. Educational disparities in self-rated health temporarily compressed during the pandemic (health disparity decreased by 3.9%) before partially reexpanding after the pandemic. Income-based physical health disparities persisted: the lowest-income women reported 7.48 poor physical health days before the pandemic versus 2.38 days for highest-income peers. Mental health decreased universally, with lowest-income women reporting 7.00 poor mental health days per year after the pandemic versus 6.09 days before the pandemic. Unemployed women experienced temporary pandemic-period health improvements (b = -2.07; P = .05) Conclusions. Although the pandemic temporarily compressed educational disparities, income and employment-based inequities persisted or widened, underscoring SES as a partial buffer and site of structural health inequality. Public Health Implications. Sustaining pandemic-era protections (expanded health care, income supports) and prioritizing mental health equity are critical to addressing systemic inequities exacerbated by crises. (Am J Public Health. 2026;116(4):502-511. https://doi.org/10.2105/AJPH.2025.308348).

Variations in Mental Distress Among Caregivers of Individuals With Chronic Illnesses and Comorbid Cognitive Impairment.

Adverse childhood experiences and cancer pain: A national cross-sectional analysis of survivors' pain outcomes.

Previous research documents a strong association between gambling and substance use, suggesting that these seemingly distinct behaviors may share similar environmental, neurobiological, and genetic causes. However, there is a dearth of credible empirical evidence on whether gambling has a causal impact on substance use or vice versa. This paper estimates the impact of gambling on substance use making use of the rapid roll-out of sports betting laws across US states. Using data from the Behavioral Risk Factor Surveillance System and a difference-in-difference (DID) estimation strategy to assess the impact of legalizing sports betting on smoking and drinking behavior among adults, we find that the legalization of online sports betting has increased binge drinking frequency-at the intensive margin among young men by approximately 10 percent, but find no discernible impact on smoking. The results are consistent across traditional two-way fixed effects models as well as more recently developed DID methods designed for staggered treatment adoption.

Mental health among US working-age adults notably worsened during the COVID-19 pandemic, following a steady decades-long decline. The impact of states' COVID-19 policies on mental health has received much attention; however, less is known about the impact of a broader set of long-standing and overarching state policy contexts. This study examines how working-age adults' mental health was associated with states' policy contexts over 30 years. It also assesses whether the pandemic disrupted the association and whether the association is more pronounced among adults without a college degree. We use nationally representative data on adults ages 25-64 in the 1993-2022 waves of the Behavioral Risk Factor Surveillance System (N = 5,891,073), merged with measures of three state policy indices. The outcomes are self-rated poor mental health days in the last 30 days and extreme distress (poor mental health in all 30 days). The main independent variable is an index that summarizes states' overarching policy contexts, on a liberal-to-conservative continuum, annually from 1993-2020. Two additional indices summarize states' COVID-19 policies, one on in-person restrictions and a second on economic supports, monthly from March 2020 to December 2022. We estimate the association between states' overarching policy contexts and mental health, net of covariates, fixed differences between states, and COVID-19 policies. During the study period, each unit increase toward state policy conservatism was associated with 0.26 additional days of poor mental health and a 7% higher probability of extreme distress. The pandemic did not disrupt these associations. State policy contexts were a stronger predictor of poor mental health among adults without a college degree than adults with a degree. States' overarching policy contexts are an important yet understudied predictor of mental health. Current and proposed changes in state policies may have important consequences for mental health among working-age adults, their families, and communities.

Background/Objectives: Adverse childhood experiences (ACEs), including physical and sexual abuse, are significantly associated with long-term health issues, particularly among socially disadvantaged populations. The study examines the social determinants of health, such as poverty, racial inequities, and limited access to care, to assess their association with adverse childhood experiences, including exposure to physical violence and sexual abuse. Methods: We performed multivariable logistic regression analyses using data from the 2023 Georgia Behavioral Risk Factor Surveillance System (BRFSS) (n = 8227) to examine associations between selected ACEs and key social determinants of health (SDOH). Results: Our results indicated that a lack of emotional and social support was associated with increased odds of witnessing parental violence (AOR = 2.00) and physical abuse (AOR = 1.90). Absence of food insecurity was associated with lower odds of witnessing parental violence (AOR = 0.65), unwanted sexual touching (AOR = 0.77), and forced sex (AOR = 0.63). Similarly, not reporting transportation barriers was associated with lower odds across ACE outcomes (AORs ranging from 0.54 to 0.65). Sexual and gender minority individuals exhibited substantially higher odds of childhood sexual abuse (AORs = 3.64-5.56). Hispanic ethnicity was associated with increased odds of physical abuse (AOR = 1.47), and older adults (ages 45-64) had greater odds of experiencing forced sex (AORs = 2.08-2.48). These findings highlight complex relationships between SDOH and early trauma. Conclusions: Trauma-informed public health strategies must address structural inequities and strengthen emotional and material support for vulnerable populations.

The 2007 to 2009 U.S. economic recession was associated with widespread job loss, housing instability, and rising mental health challenges. While previous studies have linked economic downturns to psychological distress, limited research has examined how health insurance status modifies this relationship during and after a recession. This study investigated changes in psychological distress (PD) among U.S. adults before, during, and after the 2007 to 2009 recession and examined whether insurance status mediated the relationship between economic hardship and PD. Using Behavioral Risk Factor Surveillance System (BRFSS) data from 2007, 2009, 2012, and 2013, the study applied an integrative data analysis (IDA) framework to construct composite demographic profiles and approximate longitudinal trends. Structural equation modeling (SEM), including exploratory and confirmatory factor analysis, panel modeling, and mediation analysis, was used to examine PD trends and the influence of insurance coverage and income. Exploratory and confirmatory factor analyses confirmed a two-factor structure of PD: depression and anxiety symptoms. From 2007 to 2009, PD remained stable, but levels improved between 2009 and 2012. Higher uninsured rates significantly increased PD, with a 1% increase in the uninsured population resulting in a 17.4% rise in PD. Mediation analysis showed that limited access to mental health treatment partially explained the relationship between being uninsured and increased distress. Health insurance status plays a critical role in moderating psychological distress during economic downturns. Expanding insurance coverage and integrating mental health services into economic recovery efforts may mitigate long-term mental health consequences of financial crises.

Increasing use of cannabis edibles in response to recreational cannabis legalization in the United States.

Overweight and obesity are rising globally. During perimenopause years, declining estrogen and changes in body composition increase visceral fat and insulin resistance, increasing cardiometabolic risk. To estimate trends in overweight and obesity among U.S. women aged 40-64 years, examine variations by age and state, and project prevalence to 2050. Secondary analysis of publicly available body mass index (BMI) data accessed through the Global Burden of Disease (GBD) Health Data Exchange, using pooled cross-sectional estimates and hierarchical logistic growth modeling.This sub‑study is not part of the official GBD analysis. Harmonized data from the GBD Health Data Exchange integrated National Health Interview Survey, National Health and Nutrition Examination Survey (NHANES), and Behavioral Risk Factor Surveillance System microdata (1990-2021) for nonpregnant women aged 40-64 years, with calibration of self-reported BMI to measured NHANES data. BMI categories followed WHO cutoffs. Weighted estimates were age-standardized, and hierarchical logistic models projected state-specific trends to 2050. The pooled sample included 150,842 women, representing about 90 million weighted person-years. All data were de-identified and publicly available; ethics approval and consent were not required. Combined overweight/obesity prevalence increased from 49.2% (95% uncertainty interval (UI) 45.8-52.2; 17.7 million (95% UI 16.5-18.8 million)) in 1990 to 74.2% (95% UI 68.8-79.1; 33.4 million (95% UI 31.0-35.6 million)) in 2021, and projected to reach 83.4% (95% UI 75.5-88.3; 41.7 million (95% UI 37.8-44.2 million)). In 2021, rates ranged from 68.3% in Colorado to 82.8% in Mississippi. Overweight and obesity among midlife women have increased sharply with a continuing shift from overweight to obesity. Menopause-specific preventive strategies and policies promoting physical activity and healthy diet are critical to slow future increases.

Cancer survivors are at-risk for transportation insecurity given the frequency of medical visits and cost of care. Little is known about how transportation insecurity relates to important social relationship measures adversely impacting cancer survivors (eg, loneliness, lack of emotional support). Thus, we evaluated the association between transportation insecurity and social relationship measures among patients with and without a history of cancer. Using data from the 2023 Behavioral Risk Factor Surveillance System, we characterized relationships between transportation insecurity and two social relationship measures: (1) loneliness and (2) emotional support among individuals with and without a history of cancer. We used multivariable logistic regression models to estimate associations between transportation insecurity and adverse social relationships, with sensitivity analyses for at-risk groups. Models were adjusted for sociodemographic and health-related covariates. We identified 237,180 respondents with 29,579 reporting a history of cancer (12.5%). Transportation insecurity was more common among individuals who were younger, non-White, uninsured or publicly insured, unemployed, unable to work, and not partnered. Transportation insecurity was associated with both social relationship measures (loneliness: aOR = 1.24-3.00, 95% CI; lack of emotional support aOR = 1.31-2.47, 95% CI). Although these associations were consistent across cancer and non-cancer populations, in univariate analyses individuals with a history of cancer reported transportation insecurity more often if they were younger (18 to 49 years), non-White, had Medicaid, or no insurance compared to those without a history of cancer. These findings highlight intersections between transportation insecurity and unmet social relationship needs among individuals with and without a history of cancer.=.

We examined cancer-related pain in sexual and gender minorities (SGM) compared to heterosexual cisgender populations and evaluated sociodemographic factors within SGM and heterosexual cisgender cancer survivors. We combined 2014-2023 data of the Behavioral Risk Factors Surveillance System from 23 states and Guam that administered the sexual orientation and gender identity module and the pain-specific cancer survivorship module. Our analytic sample consisted of 56,217 cancer survivors, of whom 1,655 identified as SGM. Sexual minority cancer survivors reported twice or more the prevalence of cancer pain than heterosexual cisgender survivors, with gender minority cancer survivors reporting cancer pain most frequently (28%), followed by sexual minority women (17%), and sexual minority men (14%). Sociodemographic subgroups, consisting of younger, unmarried, not employed, and those with low income, are at increased risk of experiencing cancer pain. Our findings point to heterogeneity among sexual minority cancer survivors' prevalence of pain and additional efforts to characterize gender minorities' disparities in cancer pain. There is an urgent need for evidence-based real-life clinical data characterization of SGM cancer pain disparities and efforts to reduce their cancer-related pain.

To assess racial and ethnic differences in prostate-specific antigen (PSA) screening and shared decision-making (SDM) and examine whether SDM modifies screening rates by race and ethnicity. Data from the 2021-2023 Behavioral Risk Factor Surveillance System were analyzed, including 10,778 men aged 55-69 years eligible for PSA screening. Descriptive statistics and chi-square tests assessed racial and ethnic differences in PSA screening and estimated SDM (eSDM) use. Multiple logistic regression models evaluated the impact of eSDM on PSA screening rates, including an interaction term for race and ethnicity and eSDM. Among the sample, 46% reported undergoing PSA screening in the past year. eSDM was a significant predictor of PSA screening. After adjusting for eSDM and covariates, racial disparities in screening rates were no longer significant. Only Asian American men showed a significantly lower likelihood of screening following SDM exposure compared to White men. SDM can reduce racial and ethnic disparities in PSA screening. In addition, factors like healthcare access significantly influence screening rates, requiring targeted investigation. The results call for further investigation to culturally optimize SDM.

North Dakota has one of the highest rates of binge drinking in the United States, but little is known about how the predictors of binge drinking differ between males and females within the state. Therefore, the objective of this study was to identify and compare the sex-dependent predictors of binge drinking in North Dakota. Data were obtained from the North Dakota Behavioral Risk Factor Surveillance System (BRFSS) for the years 2017-2021. The BRFSS is a population based cross-sectional telephone survey administered annually by the North Dakota Department of Health and Human Services (NDDHHS) in coordination with the Centers for Disease Control and Prevention (CDC). The study population included all males and females aged ≥ 18 years in the North Dakota BRFSS database from 2017 to 2021 who responded to the questions "During the past 30 days, how many days per week or per month did you have at least one drink of any alcoholic beverage such as beer, wine, a malt beverage or liquor?" and "Considering all types of alcoholic beverages, how many times during the past 30 days did you have five or more drinks (for men) or four or more drinks (for women) on an occasion?." Potential predictors of binge drinking were selected using a conceptual model and included: race, age, income, education, urban or rural residence, and frequent physical or mental distress. Separate binary logistic regression models of binge drinking were fitted for males and females. The odds of binge drinking declined with increasing age in both sexes. Males who were Black or other races and ethnicities besides American Indian had lower odds of binge drinking than White males. Additionally, males had significantly higher odds of binge drinking if they lived in a rural county, had a household income ≥ $75,000, or had more than a high school education compared to those who lived in an urban county, had a household income < $75,000, or had no more than a high school education. White females had significantly higher odds of binge drinking than those who were Black, and females with frequent mental distress had significantly higher odds of binge drinking than females without frequent mental distress. The predictors of binge drinking differ between males and females in North Dakota. Geographic and socioeconomic factors were significant predictors in males, but not females, while frequent mental distress was only a significant predictor of binge drinking among females. Efforts to reduce binge drinking in this state should consider potential differences in programmatic needs between the sexes.

Despite well-documented national declines in cervical cancer incidence among young women following human papillomavirus (HPV) vaccine implementation, state-level data remain limited. Using the US Cancer Statistics Database, differences in cervical cancer incidence rates for women aged 20-31 between the pre-vaccination (2000-2005) and vaccination era (2016-2021) were estimated using rate ratios (RRs) across 47 states and the District of Columbia (DC). Associations between HPV vaccination rates from the National Immunization Survey-Teen and RRs were examined using Spearman's rank test and linear regression models, adjusted for screening rates from the Behavioral Risk Factor Surveillance System. Nationwide, cervical cancer incidence rates declined by 27% (RR = 0.73, 95%CI:0.70 to 0.75) during the vaccination era, from 5.1 to 3.7 per 100,000. Reductions exceeded 50% in DC (RR = 0.48, 95%CI : 0.15 to 0.81), Rhode Island (RR = 0.48, 95%CI : 0.21 to 0.76), Michigan (RR = 0.48, 95%CI : 0.38 to 0.57), and Hawaii (RR = 0.49, 95%CI : 0.21 to 0.78), with 28 additional states achieving statistically significant reductions of 15-50%. Ten states showed slower decreases (<15%). Notably, progress was lacking in Vermont (RR = 1.11; 95%CI : 0.21 to 2.00), West Virginia (RR = 1.09; 95%CI : 0.63 to 1.56), Idaho (RR = 0.97; 95%CI : 0.42-1.52), Arkansas (RR = 0.96; 95%CI : 0.64 to 1.29), and Alabama (RR = 0.96; 95%CI : 0.71 to 1.21). Across states, higher vaccination rates were correlated with lower RRs (i.e., faster decline) (rho=-0.42, P = .0027). Every 10% increase in vaccination rates was associated with an 11.5% (95%CI : -17.2% to -5.4%) reduction in RRs, adjusted for screening rates. Declines in cervical cancer incidence in young women during the HPV vaccination era varied substantially by state, aligning with HPV vaccination rates.

This study aims to explore the association between sleep duration and healthy aging in the older U.S. adults, utilizing a nationally representative sample. Participants aged 65 and older from the 2016 Behavioral Risk Factor Surveillance System were eligible for this study. Healthy aging was defined as the absence of major chronic diseases, no physical functional limitations, and good subjective cognitive function and mental health. Logistic regression and restricted cubic spline curve analysis were employed to examine the potential association between sleep duration and healthy aging. Stratified analyses were conducted to examine the interactive effects of sleep duration with smoking, employment status, and other variables on healthy aging. 35,056 older adults (mean age 73.06 ± 5.31 years, 60.5% females) were included, among whom 5,782 (16.5%) achieved healthy aging. Sleep duration exhibited an inverted U-shaped relationship with healthy aging. Compared to those who slept for 7 h, the adjusted ORs (95% CI) of healthy aging for those who slept for ≤ 5 h, 6 h, 8 h, and ≥ 9 h were 0.51 (0.43, 0.59), 0.79 (0.72, 0.87), 0.96 (0.90, 1.03), and 0.65 (0.58, 0.73), respectively. Additionally, there was an interaction between sleep duration and employment & smoking status on healthy aging (P interaction = 0.003 & 0.009). Among the unemployed, the adjusted OR (95% CI) for healthy aging among those who slept ≤ 5 h was 0.41 (0.34, 0.49) [VS the employed: 0.75 (0.56, 1.01)]; among current and former smokers, the adjusted OR (95% CI) for healthy aging among those who slept ≤ 5 h was 0.37 (0.17, 0.82) and 0.39 (0.29, 0.51) [VS never smokers: 0.60 (0.49, 0.73)]. Both short and prolonged sleep duration may adversely impact healthy aging, especially among the unemployed and smokers. Health professionals should advise older adults that 7–8 h of sleep per day may promote overall health. Future research should explore the longitudinal relationship between sleep duration and healthy aging.

Projecting and valuing climate change impacts on anxiety and depression in the contiguous USA: a damage function approach.

Background: Little is known about the prevalence or intensity of concurrent cannabis, alcohol, and tobacco use. To address this gap, we examined the patterns and correlates of past-month tri-use and intensive tri-use among U.S. adults. Methods: We merged 2016–2023 Behavioral Risk Factor Surveillance System data and calculated the trends, patterns, and intensity of past-month concurrent cannabis, alcohol, and tobacco use among U.S. adults (18+ years). Bivariate analysis was used to compare the characteristics of respondents reporting tri-use (versus no substance use) and intensive tri-use (versus no intensive tri-use). Multivariate logistic regression was used to identify the factors associated with these substance use patterns. Results: From 2016–2023, 2.6% of U.S. adults reported tri-use and 0.5% reported intensive tri-use. The trend in intensive tri-use increased from 0.4% in 2016 to 0.6% in 2020 (p < 0.01), but stabilized through 2023 (p = 0.19). Compared to respondents who reported no intensive substance use, respondents reporting intensive tri-use were more likely to be 25–34 years of age (AOR = 2.0, 95% CI 1.4–3.0), male (AOR = 1.7, 95% CI 1.4–2.1), unable to afford care (AOR = 1.6, 95% CI 1.3–2.1), and have only a high school degree (AOR = 0.4, 95% CI 0.3–0.6). They were less likely to be Hispanic (AOR = 0.2, 95% CI 0.1–0.3), married (AOR = 0.4, 95% CI 0.3–0.5), have a higher household income (AOR = 0.6, 95% CI 0.4–0.8), or a personal doctor/provider (AO = 0.6, 95% CI 0.5–0.8). Conclusions: Among U.S. adults, 2.6% reported cannabis, alcohol, and tobacco tri-use and 0.5% reported intensive tri-use. Being younger, male, non-Hispanic, unmarried, and lacking healthcare access were associated with these outcomes.

Abstract Background: Despite breast cancer being the most diagnosed cancer among women in the United States, persistent disparities in screening mammography remain. Non-Hispanic Black, Hispanic, and American Indian/Alaska Native (AIAN) women are disproportionately affected by lower screening rates, contributing to delayed diagnoses and worse outcomes. This study aims to examine these disparities through a comprehensive analysis of national prevalence data. Methods: We used 2022 model-based, age-adjusted mammography prevalence data from the Behavioral Risk Factor Surveillance System (BRFSS), based on responses to the core question, “Have you had a mammogram in the past two years?” for women aged 50-74 years. Ethnic groups analyzed included Non-Hispanic White, Hispanic, Non-Hispanic Black, American Indian/Alaska Native (AIAN), and Asian/Pacific Islander (API). U.S. regions were defined using Census Bureau classifications: Northeast, Midwest, South, and West. All ethnic groups were included in descriptive analysis; however, stratified comparisons focused on historically underserved populations (Hispanic, Non-Hispanic Black, and AIAN) due to reliability and consistency of state-level estimates. The dataset comprised 95,728 respondents from all 50 states and D.C.(District of Columbia), with prevalence estimates age-standardized to the 2000 U.S. standard population. States or subgroups with fewer than 50 respondents were excluded. Differences across groups were assessed using Kruskal-Wallis tests and Dunn’s post-hoc comparisons with Bonferroni correction. Results: Stratified inferential analyses emphasized historically underserved populations due to consistency and completeness of data reporting. Statistically significant differences in screening prevalence were found by both ethnicity and region (Kruskal-Wallis p &amp;lt; 0.001). Non-Hispanic Black women had the highest screening rates nationally, while Hispanic and AIAN women had significantly lower rates. Regional analysis showed that Hispanic women in the West had markedly lower screening rates than those in the Northeast (adjusted p = 0.03, Dunn’s test). The most pronounced disparities were seen in the West, where both Hispanic and AIAN women were under-screened. In contrast, Non-Hispanic Black women maintained high screening coverage across all regions. The interaction effect between ethnicity and region was evident, with screening gaps varying by both demographic and geographic factors. These findings underscore the need for region- and ethnicity-specific screening interventions, particularly in areas like the Western U.S. where historically marginalized groups remain at elevated risk for under-screening. Conclusion: Improving screening coverage among Hispanic and AIAN populations—especially in underserved regions—will be critical to reducing late-stage diagnoses and improving outcomes. These findings support the urgent need for public health efforts that are community-driven, culturally tailored, and data-informed. As Medicare and Medicaid continue to evolve, proactive investment in regionally customized screening infrastructure, mobile outreach, and language-accessible education can help close persistent gaps. Continued national surveillance and improved data reporting for API and other racial groups are also essential to ensure equitable breast cancer prevention efforts. Further research is needed to understand how regional context influences screening and treatment disparities within the same ethnic populations. Citation Format: S. Goyal, A. Calderon, D. Hernandez, S. Khan, S. Chauhan, D. Nguyen. Ethnoregional Disparities in Breast Cancer Screening: A National Database Analysis [abstract]. In: Proceedings of the San Antonio Breast Cancer Symposium 2025; 2025 Dec 9-12; San Antonio, TX. Philadelphia (PA): AACR; Clin Cancer Res 2026;32(4 Suppl):Abstract nr PS4-12-19.

Racial and ethnic minoritized individuals have lower uptake of lung cancer screening (LCS). It is unclear how perceived racial discrimination in health care setting affects LCS uptake. The purpose of this study was to investigate the association between perceived racial discrimination in health care and LCS use among LCS-eligible adults in the U.S. We used population-based, cross-sectional data from the 2022 Behavioral Risk Factor Surveillance System Survey Reaction to Race module. Eligible participants were adults aged 50-79 who currently use cigarettes or quit within the past 15 years and have ≥ 20 pack-years of tobacco use history. The outcome was LCS use in the past year. The key predictor was self-reported racial discrimination experienced in a health care setting within the past 12 months. We conducted descriptive statistics, including frequencies, weighted means, and percentages and weighted multinomial multivariable logistic regression analysis. The majority of study participants were men, aged 50-64 years, non-Hispanic White, metropolitan county residents, and held high school or less education. Individuals perceiving racial discrimination had lower odds of LCS uptake in the past year compared to those who did not report such experience. The odds of LCS utilization in the past year were higher among individuals with certain characteristics, such as men (vs. women), aged 65-79 (vs. 50-64y), retired (vs. employed), and metropolitan area residents (vs. nonmetropolitan residents). LCS utilization remains low, and perceived racial discrimination is associated with low uptake of LCS. Strategies such as digital LCS resources, diversifying the health care workforce, and cultural competence training for the providers may address perceived racial discrimination and ensure equitable LCS initiatives in order to improve LCS participation.